Preventing Occupational Transmission of Globally Emerging Infectious Disease Threats

Abstract

The infection and subsequent illness of two US health care workers with Ebola in 2014 served to highlight persistent concerns about the adequacy of public health efforts to protect both the public and affected working populations from globally emerging infectious diseases. The initial guidance provided by the Centers for Disease Control and Prevention failed to adequately address worker exposure and subsequent protection of the public from Ebola. These events contributed to a climate of stigma and fear within health care systems and the public at large. The significant gaps in occupational and public health preparedness programs urgently need short- and long-term solutions. This policy statement is well aligned with previous APHA community- or population-based policy statements supporting adequate funding for federal, state, and local health departments and other organizations to help address disparities in global health preparedness and treatment of infectious diseases. Hospital and public health preparedness for globally emerging infections is an ongoing public health priority. Protecting US health care workers and other workers who must respond to infectious disease outbreaks that arise from transmission in their communities is a pivotal link in creating an effective public health preparedness program.  

Relationship to Existing APHA Policy Statements 

• Late Breaker 14-01: Preventing Occupational and Community Transmission of Ebola and Globally Emerging Infectious Disease Threats
• APHA Policy Statement 201015: Securing the Long-Term Sustainability of State and Local Health Departments 
• APHA Policy Statement 20063: Preparing for Pandemic Influenza 
• APHA Policy Statement 201014: Annual Influenza Vaccination Requirements for Health Workers 
• APHA Policy Statement 8906: Recommendations for Adult Immunization 
• APHA Policy Statement 20052: Developing a Comprehensive Public Health Approach to Influenza 
• APHA Policy Statement 8928: Occupational Transmission of Human Immunodeficiency Virus 

Problem Statement 

Hospital and public health preparedness for globally emerging infectious disease is an ongoing public health priority. Protecting US health care workers and other workers who must respond to infectious disease outbreaks that arise from transmission in their communities is a pivotal link in creating an effective public health preparedness program. In addition to hospitals or acute care facilities, many underserved populations such as elderly or disabled individuals require the services of direct care workers in long-term care facilities and in their residence homes. Community health workers serving underserved, uninsured, or underinsured individuals require services in the field, and these direct care workers must be included in health care workforce protections, particularly when community outbreaks are anticipated.

The recent cases of Ebola virus disease (EVD) in the United States remind us that infectious disease threats at both the community and global levels continue to challenge the capacity of health systems and communities to adequately protect people from exposure to microorganisms (bacteria, viruses, and spores) that may cause illness or infection and generate stigma and fear.[1–5]  

This situation also raises ethical questions about how governments should exercise public health powers to limit the liberties of some for the protection of others and to avoid stigmatization of affected health care workers.[6] The cases of transmission of EVD to two US health care workers in 2014 demonstrated significant gaps in the following areas: 

1. Protection of workers whose job duties include occupational exposures to microorganisms that cause infectious diseases
2. Preparedness among health care agencies and other affected industries such as emergency medical services, environmental services, mortuaries, transportation, waste management, and laboratory services
3. Coordination with occupational safety and health experts at the local, state, and federal levels 
4. Public health preparedness and response to proactively address emerging infectious disease threats and fear and stigma at the federal, state, and local levels 
5. Management of unnecessary quarantine procedures 

Gaps in current programs: The recent cases of EVD in the United States revealed significant gaps in occupational and public health programs that address globally emerging infectious disease threats, and there is an urgent need for both short- and long-term solutions to these issues.[2–13] In October 2013, the Association for Professionals in Infection Control and Epidemiology published the results of a readiness survey of 1,039 of its members who practiced in acute care hospitals in the United States. The survey showed that only 6% of those surveyed felt that their hospitals were fully prepared for Ebola; 20% had yet to begin training their workers.[1]

According to a report published by the Trust for America’s Health and funded by the Robert Wood Johnson Foundation (“Protecting Americans from Infectious Diseases 2014”), “[t]he Ebola outbreak has been a major wake-up call to the United States—highlighting serious gaps in the country’s ability to manage severe disease outbreaks and contain their spread.”[14] Half of the US states and Washington, DC, scored 5 or lower out of 10 key indicators related to preventing, detecting, diagnosing, and responding to outbreaks. The report further noted that, “[b]eyond Ebola, there are many other emerging diseases of concern that health officials are monitoring—MERS-CoV, pandemic flu, Marburg, dengue fever and Enterovirus D68—all of which illustrate that infectious disease threats can arise without notice.” After conducting a series of stakeholder focus groups among infectious disease experts, the National Institute of Environmental Health Sciences (NIEHS) published a report identifying training gaps for infectious disease response workers in the health care sector and other sectors affected by the Ebola crisis.[15]

A number of infectious disease experts have predicted that another influenza pandemic such as the outbreak that occurred in 1918 and 1919, which caused 500 million infections and 50 million deaths worldwide, is inevitable, and they are concerned that recent events suggest this might occur sooner rather than later.[16,17] The outbreaks of severe acute respiratory syndrome (SARS) (2003), Middle East respiratory syndrome coronavirus (MERS-CoV) (2012), and H5N1 (2003) and H1N1 (2009) influenza revealed the necessity of strengthening infectious disease preparedness programs.[18,19] 

The outbreak of SARS was spread by international air travel, a direct result of globalization. During that outbreak, health care workers were at high risk and actually accounted for a fifth of all SARS cases globally. Risk factors for infection among these workers included lack of awareness and preparedness when the disease first struck, poor institutional infection control measures, lack of training in infection control procedures, inadequate guidance on and availability of personal protection equipment, exposure to high-risk procedures such as intubation and nebulization, and exposure to unsuspected SARS patients.[18] 

Gaps in current funding: Funding for the Centers for Disease Control and Prevention (CDC) Office of Public Health Preparedness and Response (OPHPR) was reduced by $65 million in fiscal year 2013. A further reduction in funding resulted from The Budget Control Act of 2011, which eliminated a $30 million transfer of funds from the Public Health and Social Services Emergency Fund to OPHPR. Funding for the public health preparedness and response activities of the CDC was $1 billion lower in 2013 than in 2002, the first funding year after the terror attacks of September 11, 2001, and the anthrax events.[20,21] 

These experiences and threats, along with the Ebola cases in the United States, justify restoring a public health focus and dedicated funding, strengthening the preparedness of the workforce, increasing educational opportunities, and implementing innovative technologies and programs. They also support the urgent need for action by the Occupational Safety and Health Administration (OSHA), including issuance of an emergency temporary standard on infectious diseases until a permanent rule is implemented. OSHA’s only current infectious disease standard is 29 CFR 1910.1030, Occupational Exposure to Bloodborne Pathogens.[22,23] This standard was developed primarily to address the prevention of occupational transmission of hepatitis B virus, hepatitis C virus, and HIV and does not address emerging infections, including those that may be spread by means other than blood or body fluids such as by contact, droplets, or aerosols. The standard requires employers under OSHA jurisdiction to comply with a number of provisions as they relate to potential occupational exposures to blood, body fluids, and other potentially infectious materials, including conducting a risk assessment, developing a written exposure control plan, using administrative controls to prevent exposures, providing personal protective equipment (PPE), offering vaccinations, providing postexposure prophylaxis, requiring specific labeling and regulating medical waste, and conducting annual training. These same program elements should be established for all infectious diseases that are present in the workplace. The California Aerosol Transmissible Diseases Standard addresses these program elements for infectious aerosols but has regulatory authority only in California.[24–27]

There is an urgent need for rapid and reliable detection and diagnostic technologies. Diagnostic technologies allow for early detection of cases to reduce the time involved in recognizing or ruling out a suspected case. Rapid and reliable detection will reduce the use of preventive isolation and the costly, labor-intensive staffing and equipment use it requires. Early identification of cases may also help improve treatment outcomes.

In December 2014 Congress passed HR 83 (the Consolidated and Further Continuing Appropriations Act of 2015),[28] which included emergency funding for Ebola preparedness and response.[26] While this significant funding ($1.35 billion) is a major step in the right direction, it does not reflect a permanent increase in the budget line items that have been cut and that must be restored on more than an emergency basis to build an effective public health infrastructure that can deal with widespread and fatal infectious disease outbreaks.  

Outbreaks of Ebola have occurred every year since it was first identified in Zaire in 1976. With exceptional growth of the globalization of travel and population migration due to war and poverty in the last decade, transmission of infectious diseases such as Ebola is not only possible but probable. This likely probability of risk requires constant, ongoing attention, support, and funding. The Ebola virus and its strains are only one pathogen with the potential to cause illness and infection in the US population; dozens more are tracked by organizations such as the CDC and the World Health Organization. Preparing our health care facilities and public health infrastructure for the potential of any of the dozens of infectious disease exposures requires creating a long-standing infrastructure with the ability to adapt to specific threats over time.[29,30]

Gaps in personal protective equipment capabilities: The National Institute for Occupational Safety and Health (NIOSH), OSHA, NIEHS, and the InterAgency Board have all documented significant gaps in PPE technology, performance criteria, standards, test protocols, and technical, operating, and training requirements.[31,32] NIOSH has issued reports on garments designed to protect health care workers from exposure to microorganisms contained in blood and body fluids, and these documents detail the use of current test methods and their strengths and weaknesses. Also, the Institute of Medicine published a report on the use of powered air purifying respirators in health care settings, identifying problems with the currently available technology.[32]  

While it is important to address PPE construction, manufacturing, and testing parameters, improving compliance, availability, and use of PPE continues to be a major concern in US hospitals. In fact, Mitchell et al. described occupational exposures to blood in a cohort of more than 60 hospitals and noted that PPE use during incidents can vary between 25% and 75%. In addition, when considering eye exposures alone, compliance with the use of goggles and face shields can be as low as 7%. These extremely high-risk exposures and lack of compliance with PPE use create environments in which the likelihood of transmission of an emerging pathogen to a worker is high.[33]

Agency and stakeholder collaboration: According to the Bureau of Labor Statistics, 14.9 million workers were employed in the private health care sector as of January 2015, with another 1.3 million working in federal, state, and local government hospitals, representing a total of 11.5% of the entire US working population.[34] Of these individuals, approximately 11.5 million are classified as health care workers who either provide direct care to patients or come into close contact with them. There are about 35 million patient discharges in the United States each year, which means that in combination health care workers and patients constitute a substantial percentage of the US population.[35] This is an extraordinarily high number of people potentially at risk when the United States is not adequately prepared to prevent the spread of infectious diseases, particularly in the case of infectious microorganisms, such as EVD, that are spread from person to person when patients are not identified and isolated. 

CDC, NIOSH, and OSHA must continue to consult and collaborate with occupational safety and health professionals, infectious disease practitioners, those focusing on preventing illness and infection, and the broad spectrum of government, academic, industry, and labor professionals to address preparedness for and responses to these diseases. OSHA and CDC have a rich history of bringing stakeholders together to debate and help set infectious disease policies. This was the case with emerging disease threats such as HIV/AIDS in the 1980s and tuberculosis in the 1990s, as well as threats to the public’s health during natural disasters such as Hurricanes Katrina, Rita, and Sandy.[36–40] Stakeholder involvement must be maintained and improved at these agencies.[13,28,29] The role and funding of NIOSH as the leading scientific federal agency responsible for occupational safety and health research and guidelines must be restored and even increased. Successful collaborations with learning and academic institutions must continue to be extended so that both current and future public and occupational health researchers and practitioners have the foundation they need to protect the public and the workforce.

Evidence-Based Strategies to Address the Problem 

Global public health, clinical, and health care organizations base their recommendations for patient care on the peer-reviewed published literature and long-established clinical and medical practices. The guidance documents below are based on peer-reviewed research and evidence-based practice and include detailed strategies for addressing safety and health related to worker protection from exposure to EVD and other emerging infectious diseases. These guidance documents alone, however, carry no mandates, enforceability, or requirements. 

The World Health Organization (WHO) has published guidance on transmission of Ebola, as well as information on symptoms, clinical care, and infection control, in its Ebola Virus Disease Fact Sheet No. 103.[2] Domestically, CDC publishes guidance for US hospitals based on standard precautions, and this information is available in the following documents: Guidance on Personal Protective Equipment to Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting on (Donning) and Removing (Doffing); Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States; Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Persons Under Investigation for Ebola Virus Disease in the United States; and Guidance for Safe Handling of Human Remains of Ebola Patients in U.S. Hospitals and Mortuaries.[7–11]

State departments of health and public health, as well as health care facilities themselves, have developed guidelines, standards, or orders in response to domestic cases of EVD and CDC’s updated guidance. Some have created and adapted their own as a supplement to guidance from CDC and WHO. In addition, CDC’s Division of Healthcare Quality Promotion conducted site visits in coordination with state departments of health to evaluate and monitor implementation of EVD guidelines in Ebola treatment facilities. Since no additional cases of EVD have been identified in the United States, it is difficult to determine whether these protocols prevented additional transmission or whether they remain in place. However, there is mounting evidence in the peer-reviewed literature that the prevention strategies and controls in place in health care facilities will help minimize worker exposures to EVD and other globally emerging infectious diseases as well as decrease subsequent risk to the community.[41–45] Again, these practice guides and studies are not currently enforceable.

Because there are no mandated measures of compliance with guidance from CDC or WHO, it is necessary to consider standards, mandates, and regulations that do in fact protect US health care workers. Although OSHA standards are enforceable, current regulations are not specific to the hazards associated with occupational exposure to infectious disease. The OSHA standards apply to general precautions across occupations and are not prescriptive to the needs of workers exposed to globally emerging infectious disease threats. Current standards that apply to infectious diseases include the Bloodborne Pathogens Standard (29 CFR 1910.1030), the Personal Protective Equipment Standard (29 CFR 1910.132), the Respiratory Protection Standard (29 CFR 1910.134), and the Hazard Communication Standard (29 CFR 1910.1200).[22,46,47] Due to the current standards and enforcement gaps for occupational exposures to emerging infectious disease threats, this policy statement further describes the need for OSHA rulemaking with respect to an infectious disease standard. This standard would close gaps in current protections and would include coverage and controls for diseases that are transmissible by contact, droplet, and aerosol.  

California was the first state to promulgate an enforceable aerosol transmissible disease standard, and this standard provided the basis for implementing the enforceable Cal/OSHA Interim Guidance on Ebola Virus in Inpatient Hospital Settings in November 2014.[27,48] The aerosol transmissible disease rulemaking process and subsequent standard protects employees in hospitals and other settings from exposure to diseases spread by inhalation of, or mucous membrane contact with, small liquid particles of body fluids released into the air.

In addition to standards addressing modes of prevention and protection, there is an urgent need for rapid and reliable detection or diagnostic technologies, with high sensitivity and high specificity, to prevent new exposures and to initiate appropriate treatment at an earlier stage. Such innovations in clinical diagnostics have the potential to minimize the negative consequences of lengthy quarantines and use of isolation methods among patients with suspected cases while they are awaiting diagnosis. Detection and diagnostic capabilities as such were successfully and similarly addressed decades ago with similar occupational exposure threats involving hepatitis B, hepatitis C, and HIV.[38]

Opposing Arguments/Evidence 

A belief exists in some business and political sectors that there is too much government regulation and that the private sector should regulate itself. The Small Business Advocacy Review Panel instructed OSHA to bypass promulgation of a new standard because it creates undue regulation of smaller health care facilities, clinics, and offices.[26] In addition, many oppose the establishment of uniform national approaches and instead argue that states and localities should develop their own laws, standards, regulations, and guidelines. A national debate has emerged over how to balance public health safety and public fears of infectious disease spread with the rights of health care and other workers, volunteers, and troops who combat infectious diseases here in the United States and/or abroad. As well, those who oppose the creation of an infectious disease standard may believe that enough is already being done and that restoring public health funding will be too costly. Another argument is that funding should not be prioritized for preparedness activities involving health risks that are theoretical (new EVD cases in the United States or emerging pathogens yet to be identified) but, rather, should be directed toward immediate physical hazards (e.g., filling potholes or shoring up broken guardrails). 

Action Steps 

• Congress, the states, and localities should restore and maintain the public health preparedness funding (adjusted for current dollar value) that was reduced in the decade prior to the Ebola outbreak of 2014. CDC (including NIOSH) and state and local health departments should be provided with adequate funding to ensure that they are prepared for all natural and manmade globally emerging infectious disease threats.
  • Congress, states, and localities should invest greater resources in education and training in the areas of public health preparedness, worker protection, hospital preparedness, and management of stigma and fear that may be experienced by the public at large. 
  • Congress should direct funding to the development of innovative new technologies (such as those allowing rapid and reliable detection of infections with high sensitivity and specificity) and to the certification of PPE and other protective apparel used to eliminate or minimize exposures to microorganisms that cause illness and infection.
  • Congress should direct funding to the creation of research and development, implementation, and interventional collaborative (interorganizational) partnerships among public and private entities such as standards-setting groups, manufacturers, employers, academic organizations, and labor unions to protect workers and the community from emerging infectious diseases.
  • National programs or protocols should be developed and put in place for surveillance, reporting, or recording of occupational exposures to infectious disease. CDC, in partnership with NIOSH, OSHA, the Bureau of Labor Statistics, and the Food and Drug Administration, should develop protocols for employers to report when a health care worker is exposed to infectious agents. These protocols should include appropriate methods for early detection of infections. The surveillance system would begin to reveal the extent of occupational exposures and illnesses experienced by the nation’s health care workforce.
  • Federal, state, and local governments should work to advance and improve policies related to occupational safety and health, guided by the most recent scientific knowledge and CDC and NIOSH recommendations. There should be a specific focus on the limitations and problems created by blanket quarantines and travel ban policies for health care, relief, and aid workers, which have detrimental effects in terms of encouraging US health professionals to travel in order to be able to fight diseases at their source.
  • Current federal, state, and local funding should be expanded to increase the number of regional biocontainment units within health care facilities that provide the highest possible level of protection to health care workers and the public.
• The White House and Congress should direct the secretary of labor and the OSHA assistant secretary to fast-track the infectious disease standard, including consideration of an emergency temporary standard relating to occupational exposures to infectious diseases.
• The secretary of labor and the OSHA assistant secretary should consider adopting the CDC guidelines for protecting health care and allied workers or the California/OSHA Aerosol Transmissible Diseases Standard.
• The secretary of labor and the OSHA assistant secretary should create a compliance directive and a national emphasis program related to occupational exposures to infectious diseases with a focus on current OSHA standards. The directive and program should include guidance on engineering controls, PPE, respiratory protection, hazard communication, worker training, protection from bloodborne pathogens, hazardous waste operations, and emergency response, as well as the general duty clause.
• The secretary of labor and the OSHA assistant secretary should promulgate standards for workers in areas other than health care (e.g., the transportation, janitorial, and mortuary industries), in collaboration with the relevant federal agencies (e.g., Federal Aviation Administration, Department of Transportation, Department of Homeland Security), to protect them from infectious diseases.
• The secretary of labor and the OSHA assistant secretary should include a medical removal and medical removal protections benefits section in the agency’s infectious disease standard. This clause would protect workers who are exposed to or contract infectious diseases as a function of their occupation, and who are subsequently placed on job duty restriction or under isolation or quarantine, from job, wage, or benefit loss. This protection should also be extended to workers who experience behavioral health effects. 
• The secretary of labor and the OSHA assistant secretary should vigorously enforce whistleblower protection laws as well as the civil liberties of workers who raise safety and health concerns related to inadequate procedures for preventing the transmission of infectious diseases.
• NIEHS should continue to provide health and safety training programs on Ebola and infectious disease prevention through its grant program.
• Academic, community-based, and media-supported programs focusing on public health preparedness and response should be funded and expanded.
• Public health and other health-related training programs should incorporate public health preparedness and response into their core curricula and other educational forums. 
• The CDC-funded Preparedness and Emergency Response Learning Centers should be fully funded and expanded beyond the current total of 14 centers in the 50 states.
• Media professionals should be trained in ethical and crisis support reporting and information distribution strategies to help educate the public and minimize fear and stigma about infectious diseases when appropriate.
• Ethical principles should be integrated into public health decision-making processes in response to rapidly unfolding epidemics.
• There is a need for a single US health official accountable for ethics integration.
• Communication efforts should mitigate stigmatization and discrimination associated with occupational and community exposures to emerging infectious diseases.

References

1. Association for Professionals in Infection Control and Epidemiology. APIC Ebola readiness poll: results of an online poll of infection preventionists. Available at: http://www.apic.org/Resource_/TinyMceFileManager/Topic-specific/Ebola_Readiness_Poll_Results_FINAL.pdf. Accessed December 3, 2015.
2. World Health Organization. Ebola virus disease: fact sheet no. 103. Available at: http://www.who.int/mediacentre/factsheets/fs103/en/. Accessed December 3, 2015.
3. World Health Organization. Ebola response roadmap: situation report update. Available at: http://apps.who.int/iris/bitstream/10665/137185/1/roadmapupdate25Oct14_eng.pdf?ua=1. Accessed December 3, 2015.
4. World Health Organization. Statement on the first meeting of the International Health Regulations Emergency Committee on the 2014 Ebola outbreak in West Africa. Available at: http://www.who.int/mediacentre/news/statements/2014/ebola-20140808/en/. Accessed December 3, 2015.
5. Centers for Disease Control and Prevention. Cases of Ebola diagnosed in the United States. Available at: http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/united-states-imported-case.html. Accessed December 3, 2015.
6. Presidential Commission for the Study of Bioethical Issues. Ethics and Ebola: public health planning and response. Available at: http://bioethics.gov/node/4637. Accessed December 3, 2015.
7. Centers for Disease Control and Prevention. Guidance on personal protective equipment to be used by healthcare workers during management of patients with Ebola virus disease in US hospitals, including procedures for putting on (donning) and removing (doffing). Available at: http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html. Accessed December 3, 2015.
8. Centers for Disease Control and Prevention. Interim guidance for emergency medical services (EMS) systems and 9-1-1 public safety answering points (PSAPs) for management of patients with known or suspected Ebola virus disease in the United States. Available at: http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html. Accessed December 3, 2015.
9. Centers for Disease Control and Prevention. Guidance on air medical transport for patients with Ebola virus disease. Available at: http://www.cdc.gov/vhf/ebola/hcp/guidance-air-medical-transport-patients.html. Accessed December 3, 2015.
10. Centers for Disease Control and Prevention. Interim guidance for specimen collection, transport, testing, and submission for persons under investigation for Ebola virus disease in the United States. Available at: http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collection-submission-patients-suspected-infection-ebola.html. Accessed December 3, 2015.
11. Centers for Disease Control and Prevention. Guidance for safe handling of human remains of Ebola patients in US hospitals and mortuaries. Available at: http://www.cdc.gov/vhf/ebola/hcp/guidance-safe-handling-human-remains-ebola-patients-us-hospitals-mortuaries.html. Accessed December 3, 2015.
12. Centers for Disease Control and Prevention. Infection control guidelines for cabin crew members on commercial aircraft. Available at: http://www.cdc.gov/quarantine/air/managing-sick-travelers/commercial-aircraft/infection-control-cabin-crew.html. Accessed December 3, 2015.
13. Baron S, McPhaul K, Phillips S, Gershon G, Lipscomb J. Protecting home health care workers: a challenge to pandemic influenza preparedness planning. Am J Public Health. 2009;99:S301–S307.
14. Trust for America’s Health. Outbreaks: protecting Americans from infectious diseases. Available at: http://healthyamericans.org/reports/outbreaks2014/. Accessed December 3, 2015.
15. National Institute of Environmental Health Sciences. Ebola biosafety and infectious disease response training. Available at: https://www.niehs.nih.gov/about/visiting/events/pastmtg/2015/wtp_ebola/index.cfm. Accessed December 3, 2015.
16. Germann TC, Kadau K, Longini IM Jr, Macken CA. Mitigation strategies for pandemic influenza in the United States. Proc Natl Acad Sci U S A. 2006;103:5935–5940.
17. Taubenberger JK, Morens DM. 1918 influenza: the mother of all pandemics. Emerg Infect Dis. 2006;12:15–22.
18. Centers for Disease Control and Prevention. Severe acute respiratory syndrome (SARS). Available at: http://www.cdc.gov/sars/. Accessed December 3, 2015.
19. Centers for Disease Control and Prevention. Middle East respiratory syndrome (MERS). Available at: http://www.cdc.gov/coronavirus/mers/. Accessed December 3, 2015.
20. National Center for Disaster Preparedness, Columbia University. Domestic preparedness cuts in the current federal budget threaten infrastructure gains and public health preparedness. Available at: http://ncdptraining.cumc.columbia.edu/~columbia/files/911memo.pdf. Accessed December 3, 2015.
21. National Association of County and City Health Officials. Local health department job losses and program cuts: findings from the January 2012 survey. Available at: http://www.naccho.org/topics/infrastructure/lhdbudget/upload/Research-Brief-Final.pdf. Accessed December 3, 2015.
22. Occupational Safety and Health Administration. Bloodborne pathogens standard. Available at: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS. Accessed December 3, 2015.
23. Occupational Safety and Health Administration. Most frequently asked questions about the bloodborne pathogens standard. Available at: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=21010&p_text_version=FALSE. Accessed December 3, 2015.
24. Occupational Safety and Health Administration. Proposed rules: protection of workers from occupational exposure to infectious diseases. Available at: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=22115. Accessed December 3, 2015.
25. Occupational Safety and Health Administration. Infectious diseases rulemaking. Available at: https://www.osha.gov/dsg/id/index.html. Accessed December 3, 2015.
26. Occupational Safety and Health Administration. Infectious Diseases Small Business Regulatory Enforcement Fairness Act (SBREFA) panel report. Available at: http://www.regulations.gov/#!documentDetail;D=OSHA-2010-0003-0250. Accessed December 3, 2015.
27. California Occupational Safety and Health Administration. Aerosol transmissible diseases (§5199). Available at: http://www.dir.ca.gov/title8/5199.HTML. Accessed December 3, 2015.
28. United States Congress. Consolidated and Further Continuing Appropriations Act (HR 83), 2015. Available at: https://www.congress.gov/bill/113th-congress/house-bill/83. Accessed December 3, 2015.
29. National Association of County and City Health Officials. NACCHO public health funding. Available at: http://www.naccho.org/advocacy/budget.cfm. Accessed December 3, 2015.
30. American Public Health Association. Policy No. 200023. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/28/15/09/the-need-for-continued-and-strengthened-support-for-immunization-programs. Accessed December 3, 2015.
31. National Institute for Occupational Safety and Health. Considerations for selecting protective clothing used in healthcare for protection against microorganisms in blood and body fluids. Available at: http://www.cdc.gov/niosh/npptl/topics/protectiveclothing/. Accessed December 3, 2015.
32. Institute of Medicine. The use and effectiveness of powered air purifying respirators in health care: workshop summary. Available at: http://iom.nationalacademies.org/Reports/2015/Use-And-Effectiveness-of-Powered-Air-Purifying-Respirators-in-Health-Care.aspx?utm_source=IOM+Email+List&utm_campaign=7ccd31d677-. Accessed December 3, 2015.  
33. Mitchell AH. Occupational exposure to blood and body fluids in U.S. hospitals: implications of national policy. Doctoral dissertation, University of Texas School of Public Health, 2013.
34. Bureau of Labor Statistics. Current employment statistics. Available at: http://www.bls.gov/web/empsit/ceseeb1a.htm#ce_ee_table1a.f.p. Accessed December 3, 2015.
35. Centers for Disease Control and Prevention. National Hospital Discharge Survey. Available at: http://www.cdc.gov/nchs/data/series/sr_13/sr13_168.pdf. Accessed December 3, 2015.
36. InterAgency Board for Equipment Standardization and Interoperability. Recommendations on selection and use of personal protective equipment for first responders against Ebola exposure hazards. Available at: https://iab.gov/Uploads/IAB%20Ebola%20PPE%20Recommendations_10%2024%2014.pdf. Accessed December 3, 2015.
37. US Department of Homeland Security. DHS’s coordinated response to Ebola. Available at: http://www.dhs.gov/ebola-response. Accessed December 3, 2015.
38. Centers for Disease Control and Prevention. Bloodborne infectious diseases: HIV/AIDS, hepatitis B, and hepatitis C. Available at: http://www.cdc.gov/niosh/topics/bbp/sharps.html. Accessed December 3, 2015.
39. Occupational Safety and Health Administration. Hurricane preparedness and response. Available at: https://www.osha.gov/dts/weather/hurricane/preparedness.html. Accessed December 3, 2015.
40. Centers for Disease Control and Prevention. Storm, flood, and hurricane response. Available at: http://www.cdc.gov/niosh/topics/emres/pre-workers.html. Accessed December 3, 2015.
41. Tomas ME, Kundrapu S, Thota P, et al. Contamination of health care personnel during removal of personal protective equipment. JAMA Intern Med. 2015 [Epub ahead of print].
42. Peterson K, Novak D, Stradtman L, Wilson D, Couzens L. Hospital respiratory protection practices in 6 US states: a public health evaluation study. Am J Infect Control. 2015;43:63–71.
43. Weber DJ, Fischer WA, Wohl DA, Rutala WA. Protecting healthcare personnel from acquiring Ebola. Infect Control Hosp Epidemiol. 2015;36:1229–1232.
44. Chan BP, Daly ER, Talbot EA. Workplace safety concerns among co-workers of responder returning from Ebola-affected country. Emerg Infect Dis. 2015;21:2077–2079.
45. Ratnapradipa K. 2015 Ebola outbreak: implications for environmental health practice. J Environ Health. 2015;78:18–21.
46. Occupational Safety and Health Administration. Personal protective equipment standard. Available at: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9777. Accessed December 3, 2015.  
47. Occupational Safety and Health Administration. Hazard communication standard. Available at: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10099. Accessed December 3, 2015.
48. California Department of Industrial Relations, Division of Occupational Safety and Health. Interim guidance on Ebola virus in inpatient hospital settings. Available at: http://www.dir.ca.gov/dosh/documents/Cal-OSHA-Guidance-on-Ebola-Virus-for-Hospitals.pdf. Accessed December 3, 2015.